Registration No. APPLICATION FORM FOR ADMISSION IN CO-EDUCATION POLYTECHNICS IN RAJASTHAN Form No. CENTRALISED ADMISSION 2008-2009 For Office Use Only Main Merit Category Merit Male Female General Wid./Div. #### S.C. S.T. OBC M.P. Phy. Handi. T. F. W. INSTRUCTIONS : 1. Read the instructions in Para 6 of the Brochure carefully. 2. All the entries to be made in by the candidate in BLOCK LETTERS in ENGLISH only. 3. Attested copies of marksheet/s, date of birth, caste certificates , Ex-Serviceman/ Military Persons / P.H. & Income certificate must be attached with this application form. 4. Tick ("v ") the relevant boxes wherever applicable. Affix passport size photograph of the candidate duly signed by candidate and attested by a Gazzetted Officer. MALE FEMALE DD MM YYYYY 1 Gen 2 WIDOW/DIVORCED 3 SC 4 ST 5 OBC 6 MP/EXS 7 PH 1 Hindu 2 MUSLIM 3 SIKH 4 CHRISTIAN 5 OTHERS YES NO Attach Income Certificate Yes No Passed Secondary/ Sr. Son/Daughter/ Wife Son/Daughter/Wife of Person None of these Bonafide Resident Secondary Exam. as a of Employee of Raj. working in Office of Board/ of Rajasthan regular student from a Govt. Corporation/ University of school situated in Rajasthan Raj./ of Govt. of India or its organisations situated in Raj. 10. ACADEMIC RECORD Attested Copy Attached Yes No SECONDARY/EQUIVALENT EXAM. Sr.SECONDARY/EQUIVALENT EXAM. Details of ITI Certificate holders Max. Marks Marks Obt. Opptional subjects Max. Marks Marks Obt. Max. Marks Maths Maths Marks Obt. Science Physics Name of Engg. Trade Chemistry Duration Aggregate of all Subjects Aggregate Including Compulsory Subjects Year of Passing Name of Board & Year of passing Name of Board & Year of passing Name of Institute Marks Improved ? Yes / No Marks Improved ? Yes / No Marks Improved? Yes / No GOVT. OF RAJASTHAN Admission Form For Co-education Polytechnics of Rajasthan ACKNOWLEDGEMENT Registration No. :______________ Received your form number ____________________ for centralised admission to the Co-educational Polytechnic of Rajasthan for the Year 2008-2009. Please mention your registration number given above for all correspondence in future. SIGNATURE 11. Admission Required for TEXTILE DESIGN (Non-Engg Branch) If "YES" then Fill ACADEMIC RECORD 12. ACADEMIC RECORD (Filled for Engineering Branch only) 13. HAVE YOU BEEN PREVIOUSLY ENROLLED WITH BOARD OF TECHNICAL EDUCATION, RAJASTHAN? YES NO EXAMINATION YEAR OF PASSING NAME OF SCHOOL/COLLEGE BOARD/ UNIVERSITY OPTIONAL SUBJECT MAX. MARKS MARKS OBTAINED % Sr. Secondary/ 12th or equivalent Graduation Post Graduation YEAR NAME OF SCHOOL/COLLEGE PLACE BOARD/UNIVERSITY 2007-2008 2006-2007 2005-2006 YES NO IF YES, ENROLLMENT No./SPN _____________ BRANCH ________________ YEAR ______________________________ POLYTECHNIC ___________ It is certified that (i) All the entries in this form have been made by me and are all correct. I Shall be responsible for any incorrect information provided by me. (ii) I have read all the information and rules given in the brochure. I shall abide by all the rules of the Polytechnic, Hostel and Board of Technical Education, Rajasthan. Signature of Candidate DECLARATION BY FATHER/GUARDIAN I_______________________________________________________ (Father's/Guardian's Name) of candidate Sh./Ms._______________________________________ take all the responsibilities for his/her conduct & maintenance of discipline of my Son/Daughter/Wife/Ward during the duration of his/her studies in the Polytechnic. The information given by him/her in the form are correct. Signature of Father/Guardian For Office Use Only ELIGIBILITY MARKS MED. CERT. D.O.B. SIGNATURE OF CHECKER ADMITTED NOT ADMITTED BRANCH ___________________________COLLEGE______________________ FEES DEPOSITED OFFICER INCHARGE (Acknowledgement Slip) Candidate to write here Name & Address Name ________________________________________ Address _______________________________________ _______________________________ Pin Code ___________________ Sender : Co-ordinator Central Admission & Principal, Govt. Polytechnic College, Jodhpur Affix Proper Ticket GOVT. OF RAJASTHAN Admission Form For Co-education Polytechnics of Rajasthan ACKNOWLEDGEMENT Registration No. :________ Received your form number ____________________ for centralised admission to the Co-educational Polytechnic of Rajasthan for the Year 2008-2009. Please mention your registration number given above for all correspondence in future. SIGNATURE (Acknowledgement Slip) Candidate to write here Affix Name & Address Name ___________________________________ Proper Ticket Address _________________________________ _________________________________ _________________________________ Pin Code ___________________ Sender : Co-ordinator Central Admission & Principal, Govt. Polytechnic College, Jodhpur
